Martha’s Vineyard Boards of Health Tick-Borne Illness Initiative

1. Martha’s Vineyard Boards of Health Tick-Borne Illness Initiative MDPH Internship 2012 Hannah Emily Nichols

2. Martha’s Vineyard • Martha’s Vineyard is an island off the coast of MA • Year-round population: 20,000 • Summer population: 100,000 • Tick-borne illnesses are endemic on the island • High deer population • Mild climate • Vast undeveloped land

3. Tick-Borne Illness Initiative • Mission: To reduce the incidence and medical consequences of tick-borne illnesses through public education and modification of disease transmission vectors • Island-Wide Board of Selectman Resolution • Public Education • Resident population, tourist population, website and videos • Medical Education • Standard of care: Prophylatic vs. symptomatic treatment • Environmental • Outside workers; landscape of the island, deer population www.MVBOH.org

4. MDPH Internship • Assess under-reporting of Lyme disease on Martha’s Vineyard • 2010 • 25 confirmed cases of Lyme disease reported to CDC • Island pharmacies filled enough Doxycycline prescriptions to treat >1200 patients for Lyme disease

5. Confirmed Cases • Patient must have “Bulls Eye” or Erythema migrans rash (<40% of Island cases have the EM rash) • OR have positive lab testing (many cases are diagnosed and treated based on symptoms, without lab testing) • Positive Results are often reported to public health department of patient’s primary residence • Physician offices lack time and financial resources to do the paperwork

6. Incidence Data for TBI: A New Approach • Goal: Retrospectively collect incidence data of Tick-borne illnesses (TBI) • Methods: Total number of Doxycycline prescriptions and total numbers of doses (tablets and pills) were collected from island pharmacies for years 2008-2011. • Number of prescriptions and doses were unavailable for one pharmacy; wholesaler information was used to estimate numbers*

7. TBI Incidence Findings

8. Payor Database • Using Doxycycline Rxs as a surrogate for Lyme Disease • Physicians and pharmacists interviewed on the island estimated that >90% of Doxycycline prescriptions were used for TBIs • Doxycycline Rxs by month for all 5 Island zipcodes, available 2 weeks after the end of the month • Rx for <14 days or >14 days • Primary Residence: Martha’s Vineyard, MA, or out-of-state

9. Incidence Data for TBI:An Old Approach • Methods: A Linelist/Spreadsheet approach to Lyme disease was implemented in three private physician offices. Lyme disease patient information was collected from medical records from the Martha’s Vineyard Hospital Emergency Department.

10. Linelist/Spreadsheet • Spreadsheet included the following information: • Patient Name, Permanent Address, DOB, Gender, MV Town • Prophylaxis for Tick Bite Only (Y/N) • Date of Symptom Onset, EM Rash (Y/N), Arthritis (Y/N), Bells Palsy (Y/N), Radiculoneuropathy(Y/N), Lymphocytic Meningitis (Y/N), 2nd or 3rd Degree Heart Block (Y/N), Other Lyme Symptoms, Labs Sent (Y/N)

11. Linelist/Spreadsheet Conclusions • The approach identified approximately 100 Lyme disease patients for the month of July • Out-of-state residents were identified • Time constraints and volume of patients were major barriers for physician offices

12. MV Hospital Findings • 136 patients were tested for Lyme disease in the Emergency Department in July 2012 • 60 of the patients tested were treated with Doxycycline or Amoxicillin and identified as probable Lyme patients to the MDPH • Lab Results: 21/60 tested positive for Lyme disease • Symptoms: 11/60 EM Rash, 2/60 Bell’s Palsy • Other symptoms: unexplained weakness, joint pain, fatigue, malaise, fever, tick bite

13. Hospital Findings Cont’d • Residence: • 27/60 permanent Martha’s Vineyard residents • 18/60 off-island MA residents • 45/60 total MA residents • 15/60 out-of-state residents • Other Diagnoses: 11/60 patients were treated with either 21 or 28 days of Doxycycline and were not diagnosed with Lyme but the following: • Lyme Disease Risk, Unexplained Weakness, Febrile Illness, Myalgia, Rash

14. Conclusions • Vast discrepancy between reported cases of Lyme and suspected cases of Lyme disease are evident • Linelist/Spreadsheet approach increased the number of cases reported and included out-of-state patients • Payor Database/Prescription approach is a new way to capture estimated real-time incidence data

15. Moving Forward • Widening the definition of “confirmed” Lyme disease case; or promote reporting of “suspected” cases • Apply payor database approach to other diseases in the future; can also capture other trends from the information: • Prophylatic vs. therapeutic treatment